Ebola Diary: On the Ground in Sierra Leone, Part 2

Second installment in a CDC fellow's account of her experiences tracking the spread of the Ebola virus in West Africa.

Kimmie Pringle, MD, an Epidemic Intelligence Service officer with the CDC and board-certified emergency medicine physician, began a 4-week rotation in Sierra Leone on the morning of Sept. 24. In this five-part series, which began Sunday, she describes her experiences as they happened.

Pringle's mission, along with 11 CDC colleagues, was to track the spread of the Ebola virus and to break the chain of transmission between contacts. This meant traveling to isolated villages where foreign healthcare workers were not always welcome, accepting heart-breaking decisions to keep staff and patients safe, and leaving far sooner than she would have liked.

From the moment Pringle's journey began, she never stopped trying to understand the harsh, beautiful, and complicated world she'd stepped into. Pringle witnessed the anger, fear, and suspicion pervasive in parts of West Africa, particularly in regions that have experienced years of violence and loss, but still she saw hope.

NOTE: This "diary" has been edited for length, clarity, and the security of certain individuals. When names or places have been changed those changes are indicated with an asterisk.

A Tale of Two Treatment Centers

Oct. 5, 2014

Entering the changing tent at the international aid agency's* Ebola treatment center feels like being under a magnifying glass in direct sunlight. I'm dripping by the time I've put on my paper scrubs and black rubber boots.

The purpose of our visit is to coordinate a meeting between the district surveillance team and the international organization and ensure that there is a clear line of communication between the two. Now that the aid organization has assumed clinical care for Ebola patients, the surveillance team is worried that they may miss cases that self-present for clinical care to this site.

Our international colleagues usher us around the low-risk zone (nontreatment area of the facility), which sits next to the high-risk zone (suspected and confirmed Ebola patients). Each area is designated with a white tent (or tents) with labels and the agency's logo. There's a station to get basic supplies such as scrubs and boots, a changing tent, administrative tents holding computers, and an endless supply of water. There are three different tents to don PPE [personal protective equipment] depending on whether one will enter the suspect, probable, or confirmed case ward. Shallow ditches in the ground hold water pipes which flow from low-risk to high-risk areas to avoid intra-site contamination. We visit the ambulance triage area to identify a potential location where Christopher, the district surveillance officer, can collect names of patients from Kenema admitted here.

I sense that the Kenema district employees still feel threatened given the financial power of this organization. But the international agency reassures Christopher that they have no intention to take over surveillance and will offer manpower and logistical support, but that their focus is clinical care. I believe them.

Christopher seemed satisfied with the results, and we return to the changing tent. The heat intensifies as I walk into the tent and remove the paper scrubs. I drop my boots through a hole in the wall into a large bucket filled with bleach, and then leave through the exit path marked by the orange mesh gates to the designated chlorine sprayer. The final stop is to wash my hands with bleach. The entry and exit procedures are specific and enforced. I appreciated their attention to detail.

I jump in the car and direct the air conditioning towards my face as we drive back to Kenema Government Hospital (KGH).

To the relief of many (including hospital staff), when I first arrived at KGH it was shutting down all Ebola care. An international aid organization had opened a hospital and had enough space to care for Kenema patients. But as the Ebola epidemic spread across the country towards more populous areas, the agency's bed capacity was quickly reached with transfers coming from Freetown, 4.5 to 5.5 hours away, daily.

Now Kenema's patients have nowhere to go. After much debate, it was decided that KGH would supplement the international organizations and reopen as an Ebola Holding Center (or Suspect Ward) only. While few cases were present in Kenema, I did not worry too much.

KGH is shaped with like an "E." Dogs run through the wards, women with buckets of bread and fried meat sell to patients, family members do laundry in the courtyard, and child laborers roam the halls with bags of water and soda.

It's an open hospital, and there is no control of who enters, when or why. This system is encouraged by the lack of infrastructure found at any public hospital in low- and middle-income countries where it is expected that the family feeds, bathes, and provides basic needs for patients.

If you drew a fourth arm out of the "E" on the very end, parallel to the road entering the hospital, this is where you find the Ebola Holding Center.

Now, after several weeks of success, Kenema is experiencing a surge of cases. The surveillance team identified three clusters and the index cases all from outside of Kenema District: one imported case, who avoided the ambulance by taking a motorcycle on back roads from a different district; the second, a pastor who contracted Ebola while officiating at a funeral in another district; and the third, an individual with an international relationship.

Three separate villages, like fireworks launching in the air and then exploding into multiple tiny parts. BOOM. BOOM. BOOM. One case quickly erupted into many, scattering to nearby villages. Movement among the people here is fluid and the family unit is held sacred. Traditional burials occurred in all three villages, not necessarily on the index case, but on secondary cases.

With this surge, I worry about the remaining healthcare workers at KGH. Just as it would not be fair to compare my infectious disease knowledge to that of a fellowship-trained infectious disease doctor, I feel comparing these internationally managed Ebola specialty hospitals with the public hospital in Kenema is equally unfair.

The international Ebola treatment centers are built with intentional design placing major emphasis on preventing nosocomial transmission. Suspects and confirmed patients are kept in different tents, the number of patients seen scales up gradually as staff become comfortable, water drainage with careful piping outline each section of the Ebola Care Center. Kenema Government Hospital is not afforded this luxury. It's built to see all comers, not just Ebola patients.

Besides the physical structure of buildings, systemic issues in case management remain at KGH. Many staff appear unmotivated, which results in inefficiency in managing the suspect ward. Their indifference may have initially kept them alive, as the hospital leadership and those most involved in care in the early months, over 50 people in total (more than 10% of all hospital staff), have died.

Currently, patients have been left in the Suspect Ward positive for days. When they become critical, then the alarm sounds and they are moved to the international aid hospitals, often to die within the first few hours of arrival.

However, the staff face challenges beyond their control. At the Ebola Holding Centers where "suspect" cases go, testing requires some patients to spend prolonged periods of time there. For the PCR test to rule out Ebola, the person must have symptoms for 3 days. Therefore, someone showing up on the first day of symptoms will be tested, but if negative must wait an additional 2 days in the Ebola Holding Center for a second test. Currently, development of a rapid test is underway. Patients reporting to KGH have started to give false names and contact information. This prevents us from tracking their lab results to know who is positive.

Clinical management is intimately related to the surveillance effort, and weak clinical management makes the elimination of Ebola in Kenema impossible due to nosocomial transmission. Having an accurate census is paramount for our surveillance officers. Secondly, we need to know who is positive and their community for obvious reasons.

The surveillance pillar is so strong here, however, that I'm confident we will catch cases in the community.

Now, we support clinical management by helping them to maintain an accurate census, quickly identify positive and negative patients and arrange the appropriate transfers and discharges. However, this is difficult given we are forbidden from entering the Ebola Holding Center, so we assist at a distance.

Hope is not lost in Kenema, but interacting with case management feels a bit like walking in mud. Deep mud.